Telemedicine, a term coined in the 1970s, which literally means “healing at a distance”, signifies
the use of ICT to improve patient outcomes by increasing access to care and medical information. Recognizing that there is no one definitive definition of telemedicine – a 2007 study found
104 peer-reviewed
definitions of the word – the World Health Organization has adopted the
following broad description:
‘The delivery of health care services, where distance is a critical factor, by all
health care professionals using information and communication technologies
for the exchange of valid information for diagnosis, treatment and prevention
of disease and injuries, research and evaluation, and for the continuing
education of health care providers, all in the interests of advancing the health
of individuals and their communities.’
TELEHEALTH
(NEJM Catalyst defines telehealth as)
‘The delivery and facilitation of health and health-related services including
medical care, provider and patient education, health information services,
and self-care via telecommunications and digital communication
technologies.’ 
Telemedicine and Telehealth
The terms telemedicine and telehealth bring with them plenty of debate among individuals in the healthcare field. One reason for this debate is due to the varying definitions pertaining to the terms themselves. Some experts consider telemedicine to be physician-focused and telehealth to include all health professionals in general. As technology in the medical field continues to advance, the two terms will likely become more distinguishable. With these advances, there are fortunately industry experts like VSee that keep up with the varying changes for physicians and hospitals. Healthcare organizations interested in implementing telehealth or telemedicine do not have to do so alone.
REGISTERED MEDICAL PRACTITIONER
‘A Registered Medical Practitioner [RMP] is a person who is enrolled in the State Medical Register or the Indian Medical Register under the Indian Medical Council Act 1956.’ [IMC Act, 1956]
SCOPE:-
Within the broad paradigm of telemedicine, these guidelines will be published under the IMC Act and are for privileged access only. These guidelines are designed to serve as an aid and tool to enable RMPs to effectively leverage Telemedicine to enhance healthcare service and access to all
- The guidelines are meant for RMPs under the IMC Act 1956
- The guidelines cover norms and standards of the RMP to consult patients via telemedicine
- Telemedicine includes all channels of communication with the patient that leverage Information Technology platforms, including Voice, Audio, Text & Digital Data exchange.
EXCLUSIONS: The guidelines specifically explicitly exclude the following:
- Specifications for hardware or software, infrastructure building & maintenance
- Data management systems involved; standards and interoperability
- Use of digital technology to conduct surgical or invasive procedures remotely
- Other aspects of telehealth such as research and evaluation and continuing education of healthcare workers
- Does not provide for consultations outside the jurisdiction of India
REGISTERED MEDICAL PRACTITIONERS ARE ENTITLED TO PRACTICE TELEMEDICINE: ALL OF THEM WILL TAKE AN ONLINE COURSE ON PRACTICE OF TELEMEDICINE;
- A Registered Medical Practitioner is entitled to provide telemedicine consultation to patients from any part of India
- RMPs using telemedicine shall uphold the same professional and ethical norms and standards as applicable to traditional in-person care, within the intrinsic limitations of telemedicine
- To enable all those RMPs who would want to practice telemedicine get familiar with these Guidelines as well as with the process and limitations of telemedicine practice:
- An online program will be developed and made available by the Board of Governors in supersession of Medical Council of India.
- All registered medical practitioners intending to provide online consultation need to complete a mandatory online course within 3 years of its notification.
- In the interim period, the principles mentioned in these guidelines need to be followed.
- Thereafter, undergoing and qualifying such a course, as prescribed, will be essential prior to practice of telemedicine.
Tools for Telemedicine;
RMP may use any telemedicine tool suitable for carrying out technology-based patient consultation
e.g. telephone, video, devices connected over LAN, WAN, Internet, mobile or landline phones, Chat
Platforms like WhatsApp, Facebook Messenger etc., or Mobile App or internet based digital
platforms for telemedicine or data transmission systems like Skype/ email/ fax etc.
Irrespective of the tool of communication used, the core principles of telemedicine practice remain
the same.
Telemedicine applications can be classified into four basic types, according to the mode of
communication, timing of the information transmitted, the purpose of the consultation and the
interaction between the individuals involved—be it RMP-to-patient / caregiver, or RMP to RMP
According to the Mode of Communication
- Video (Telemedicine facility, Apps, Video on chat platforms, Skype/Face time etc.)
- Audio (Phone, VOIP, Apps etc.)
- Text Based: o Telemedicine chat based applications (specialized telemedicine smartphone Apps, Websites, other internet-based systems etc.) o General messaging/ text/ chat platforms (WhatsApp, Google Hangouts, Facebook Messenger etc.) o Asynchronous (email/ Fax etc.)
Guidelines for Telemedicine in India
The professional judgment of a Registered Medical Practitioner should be the guiding principle for
all telemedicine consultations: An RMP is well positioned to decide whether a technology-based
consultation is sufficient or an in-person review is needed. Practitioner shall exercise proper
discretion and not compromise on the quality of care. Seven elements need to be considered before
beginning any telemedicine consultation (see panel)
Seven Elements to be considered before
any telemedicine consultation
- Context
- Identification of RMP and Patient
- Mode of Communication
- Consent
- Type of Consultation
- Patient Evaluation
- Patient Management
TELEMEDICINE SHOULD BE APPROPRIATE AND SUFFICIENT AS PER CONTEXT
The Registered Medical Practitioners should exercise their professional judgment to decide whether
a telemedicine consultation is appropriate in a given situation or an in-person consultation is needed
in the interest of the patient. They should consider the mode/technologies available and their
adequacy for a diagnosis before choosing to proceed with any health education or counseling or
medication. They should be reasonably comfortable that telemedicine is in the patient’s interest
after taking a holistic view of the given situation
Complexity of Patient’s health condition;
Every patient/case/medical condition may be different, for example, a new patient may present with
a simple complaint such as headache while a known patient of Diabetes may consult for a followup with emergencies such as Diabetic Ketoacidosis. The RMP shall uphold the same standard of care
as in an in-person consultation but within the intrinsic limits of telemedicine.
IDENTIFICATION OF THE REGISTERED MEDICAL PRACTITIONER AND THE PATIENT IS REQUIRED
- Telemedicine consultation is should not be anonymous: both patient and the RMP need to know each other’s identity.
- An RMP should verify and confirm patient’s identity by name, age, address, email ID, phone number, registered ID or any other identification as may be deemed to be appropriate. The RMP should ensure that there is a mechanism for a patient to verify the credentials and contact details of the RMP.
- For issuing a prescription, the RMP needs to explicitly ask the age of the patient, and if there is any doubt, seek age proof. Where the patient is a minor, after confirming the age, tele consultation would be allowed only if the minor is consulting along-with an adult whose identity needs to be ascertained.
- An RMP should begin the consultation by informing the patient about his/her name and qualifications.
- Every RMP shall display the registration number accorded to him/her by the State Medical Council/MCI, on prescriptions, website, electronic communication (WhatsApp/ email etc.) and receipts etc. given to his/her patients .
MODE OF TELEMEDICINE
Multiple technologies can be used to deliver telemedicine consultations. All these technology
systems have their respective strengths, weaknesses and contexts in which they may be appropriate
or inadequate in order to deliver proper care.
Primarily there are 3 modes: Video, Audio or Text (chat, images, messaging, email, fax etc.). Their
strengths, limitations and appropriateness as detailed in Section 2 need to be considered by the
RMP.
There may be situations where in order to reach a diagnosis and to understand the context better; a
real-time consultation may be preferable over an asynchronous exchange of information. Similarly,
there would be conditions where an RMP could require hearing the patient speak, therefore, a voice
interaction may be preferred than an email or text for a diagnosis. There are also situations where
the RMP needs to visually examine the patient and make a diagnosis. In such a case, the RMP could
recommend a video consultation. Considering the situation, using his/her best judgment, an RMP
may decide the best technology to use to diagnose and treat.
PATIENT CONSENT
Patient consent is necessary for any telemedicine consultation. The consent can be Implied or explicit
depending on the following situations
- If, the patient initiates the telemedicine consultation, then the consent is implied2
- An Explicit patient consent is needed if: A Health worker, RMP or a Caregiver initiates a Telemedicine consultation.
2
Implied Consent: In an in-person consultation, it is assumed the patient has consented to the consult by his/her actions.
When the patient walks in an OPD, the consent for the consultation is taken as implied. Like an in-person consultation, for
most of the tele-consultations the consent can be assumed to be implied because the patient has initiated the consultation
- An Explicit consent can be recorded in any form. Patient can send an email, text or audio/video message. Patient can state his/her intent on phone/video to the RMP (e.g. “Yes, I consent to avail consultation via telemedicine” or any such communication in simple words). The RMP must record this in his patient records.
EXCHANGE OF INFORMATION FOR PATIENT EVALUATION
Patient’s Information
- An RMP would use his/her professional discretion to gather the type and extent of patient information (history/examination findings/Investigation reports/past records etc.) required to be able to exercise proper clinical judgement.
- This information can be supplemented through conversation with a healthcare worker/provider and by any information supported by technology-based tools.
- If the RMP feels that the information received is inadequate, then he/she can request for additional information from the patient. This information may be shared in real time or shared later via email/text, as per the nature of such information. For example, an RMP may advise some laboratory or/and radiological tests to the patient. In such instances, the consult may be considered paused and can be resumed at the rescheduled time. An RMP may provide health education as appropriate at any time.
- Telemedicine has its own set of limitations for adequate examination. If a physical examination is critical information for consultation, RMP should not proceed until a physical examination can be arranged through an in-person consult. Wherever necessary, depending on professional judgement of the RMP, he/she shall recommend:
- - Video consultation
- - Examination by another RMP/ Health Worker ;
- - In-person consultation
- The information required may vary from one RMP to another based on his/her professional experience and discretion and for different medical conditions based on the defined clinical standards and standard treatment guidelines.
- RMP shall maintain all patient records including case history, investigation reports, images, etc. as appropriate.
TYPES OF CONSULTATION: FIRST CONSULT/ FOLLOW-UP CONSULT
There are two types of patient consultations, namely, first consult and the follow-up consult.
An RMP may have only a limited understanding of the patient seeking teleconsultation for the first time,
when there have been no prior in-person consultation. However, if the first consult happens to be via
video, RMP can make a much better judgment and hence can provide much better advice including additional
medicines, if indicated.
On the other hand, if a patient has been seen in-person earlier by the RMP, then it is possible to be more
comprehensive in managing the patient.
First Consult means
- The patient is consulting with the RMP for the first time; or
- The patient has consulted with the RMP earlier, but more than 6 months have lapsed since the previous consultation; or
- The patient has consulted with the RMP earlier, but for a different health condition
Follow-Up Consult(s) means
- The patient is consulting with the same RMP within 6 months of his/her previous inperson consultation and this is for continuation of care of the same health condition. However,
it will not be considered a follow up if:
- There are new symptoms that are not in the spectrum of the same health condition; and/or
- RMP does not recall the context of previous treatment and advice
PATIENT MANAGEMENT: HEALTH EDUCATION, COUNSELING & MEDICATION
If the condition can be appropriately managed via telemedicine, based on the type of consultation,
then the RMP may proceed with a professional judgement to:
- o Provide Health Education as appropriate in the case; and/or
- o Provide Counseling related to specific clinical condition; and/or
- o Prescribe Medicines
Health Education: An RMP may impart health promotion and disease prevention messages. These
could be related to diet, physical activity, cessation of smoking, contagious infections and so on.
Likewise, he/ she may give advice on immunizations, exercises, hygiene practices, mosquito control
etc
Counseling: This is specific advice given to patients and it may, for instance, include food restrictions,
do’s and don’t’s for a patient on anticancer drugs, proper use of a hearing aid, home physiotherapy,
etc to mitigate the underlying condition. This may also include advice for new investigations that
need to be carried out before the next consult
Prescribing Medicines
Prescribing medications, via telemedicine consultation is at the professional discretion of the RMP. It
entails the same professional accountability as in the traditional in-person consult. If a medical condition
requires a particular protocol to diagnose and prescribe as in a case of in-person consult then same
prevailing principle will be applicable to a telemedicine consult.
RMP may prescribe medicines via telemedicine ONLY when RMP is satisfied that he/ she has gathered
adequate and relevant information about the patient’s medical condition and prescribed medicines are in
the best interest of the patient.
Prescribing Medicines without an appropriate diagnosis/provisional diagnosis will amount to a professional
misconduct.
Specific Restrictions
There are certain limitations on prescribing medicines on consult via telemedicine depending upon
the type of consultation and mode of consultation.
The categories of medicines that can be
prescribed via tele-consultation will be as notified in consultation with the Central Government from
time to time.
The categories of medicines that can be prescribed are listed below:
List O: It will comprise those medicines which are safe to be prescribed through any mode of
teleconsultation. In essence, they would comprise of
- Medicines which are used for common conditions and are often available ‘over the counter’. For instance, these medicines would include, paracetamol, ORS solutions, cough lozenges etc
- Medicines that may be deemed necessary during public health emergencies.
This would be an inclusion list, containing relatively safe medicines with low potential for abuse Is a list of medication which RMP can prescribe in a patient who is undergoing follow-up consult, as a refill.
List B: Is a list of medication which RMP can prescribe in a patient who is undergoing follow-up
consultation in addition to those which have been prescribed during in-person consult for the
same medical condition.
Prohibited List: An RMP providing consultation via telemedicine cannot prescribe medicines in
this list. These medicine have a high potential of abuse and could harm the patient or the
society at large if used improperly
- Medicines listed in Schedule X of Drug and Cosmetic Act and Rules or any Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances, Act, 1985.
Issue a Prescription and Transmit
- If the RMP has prescribed medicines, RMP shall issue a prescription as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations and shall not contravene the provisions of the Drugs and Cosmetics Act and Rules. A sample format is suggested in Annexure 2
- RMP shall provide photo, scan, digital copy of a signed prescription or e-Prescription to the patient via email or any messaging platform
- In case the RMP is transmitting the prescription directly to a pharmacy, he/ she must ensure explicit consent of the patient that entitles him/her to get the medicines dispensed from any pharmacy of his/ her choice
MEDICINE LISTS.Annexure 1
List O
Common over-the counter medications such as
o Antipyretics: Paracetamol
o Cough Supplements: Lozenges,
o Cough/ Common-cold medications (such as combinations of Acetylcysteine, Ammonium
Chloride, Guaifensen, Ambroxol, Bromhexene, Dextromethorphan)
o ORS Packets
o Syrup Zinc
o Supplements: Iron & Folic Acid tablets, Vitamin D, Calcium supplements
o Etc
Medications notified by Government of India in case from time to time on an Emergency basis
o Such as Chloroquine for Malaria control for a specific endemic region, when notified by
Government
List A
First Consult Medications (Diagnosis done on video mode of consultation) such as
o Ointments/Lotion for skin ailments: Ointments Clotrimazole, Mupirocin, Calamine Lotion,
Benzyl Benzoate Lotion etc
o Local Ophthalmological drops such as: Ciprofloxacillin for Conjunctivitis, etc
o Local Ear Drops such as: Clotrimazole ear drops, drops for ear wax etc..
o Follow-up consult for above medications
Follow-up medications for chronic illnesses for ‘re-fill’ (on any mode of consultation) such as
medications for
o Hypertension: Enalapril, Atenolol etc
o Diabetes: Metformin, Glibenclamide etc
o Asthma: Salmetrol inhaler etc
o Etc
List B
On follow-up, medications prescribed as ‘Add-on’ to ongoing chronic medications to optimize
management such as for hYpertension: Eg, add-on of Thiazide diuretic with Atenolol
o Diabetes: Addition of Sitagliptin to Metformin
o Etc
Referance;
0 Comments